Impact of cardiac rehabilitation on depression and its associated mortality

Depressive Symptoms, Cardiac Disease Severity, and Functional Status in Patients With Coronary Artery Disease (from the Heart and Soul Study)

Patient-reported health status is highly valued as a key measure of health care quality, yet little is known about the extent to which it is determined by subjective perception compared with objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived functional status in patients with stable coronary artery disease. We assessed depressive symptoms, severity of cardiovascular disease, and perceived functional status in a cross-sectional study of 1,023 patients with stable coronary artery disease. We compared the extent to which patient-reported functional status was influenced by depressive symptoms versus objective measures of disease severity. We then evaluated perceived functional status as a predictor of subsequent cardiovascular hospitalizations during 8.8 years of follow-up. Patients with depressive symptoms were more likely to report poor functional status than those without depressive symptoms (44% vs 17%; p <0.001). After adjustment for traditional risk factors and co-morbid conditions, independent predictors of poor functional status were depressive symptoms (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.89 to 3.79), poor exercise capacity (OR 2.30, 95% CI 1.65 to 3.19), and history of heart failure (OR 1.61, 95% CI 1.12 to 2.29). Compared with patients who had class I functional status, those with class II functional status had a 96% greater rate (hazard ratio 1.96, 95% CI 1.15 to 3.34) and those with class III or IV functional status had a 104% greater rate (hazard ratio 2.04, 95% CI 1.12 to 3.73) of hospitalization for HF, adjusted for baseline demographic characteristics, co-morbidities, cardiac disease severity, and depressive symptoms. In conclusion, depressive symptoms and cardiac disease severity were independently associated with patient-reported functional status. This suggests that perceived functional status may be as strongly influenced by depressive symptoms as it is by cardiovascular disease severity.

The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS)

Background

The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.

Design

Structured review and meta-analysis.

Methods

Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.

Results

Out of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; rCCS: HR 0.64, 95% CI 0.49–0.84; odds ratio 0.20, 95% CI 0.08–0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54–0.70) and in mixed CAD populations.

Conclusions

CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

The Role of Body Habitus in Predicting Cardiorespiratory Fitness: The FRIEND Registry

This study aimed to validate and cross-validate a non-exercise prediction model from a large and apparently healthy US cohort of individuals who underwent an analysis of body habitus (waist circumference (WC) and body mass index (BMI)) with measured CRF. The large cohort (5 030 individuals) was split into validation (4 030) and cross-validation (1 000) groups, whereby waist circumference and maximal aerobic capacity (VO2max) were assessed by rigorously approved laboratories. VO2max was estimated in 2 multiple regression equations using age, sex and either WC (r=0.77; standard error of the estimate (SEE) 6.70 mLO2∙kg(-1)∙min(-1)) or BMI (r=0.76; SEE 6.89 mLO2∙kg(-1)∙min(-1)).Cross-validation yielded similar results. However, as VO2max increased, there was increased bias, suggesting VO2max may be underestimated at higher values. Both WC and BMI prediction models yielded similar findings, with WC having a slightly smaller SEE. These measures of body habitus appear to be adequate in predicting CRF using non-exercise parameters, even without a measure of physical activity. Caution should be taken when using these equations in more fit individuals.

Clinical predictors of depression treatment outcomes in patients with coronary heart disease

OBJECTIVES

Patients with coronary heart disease (CHD) who respond to treatment for depression are at lower risk of mortality than are nonresponders. This study sought to determine whether variables that have been shown to predict both depression treatment outcomes in psychiatric patients and cardiac events in patients with CHD, also predict poor response to depression treatment in patients with CHD.

METHODS

One hundred fifty-seven patients with stable CHD who met the DSM-IV criteria for a major depressive episode were treated with cognitive behavior therapy (CBT) for 16weeks, either alone or in combination with an antidepressant.

RESULTS

The mean Beck Depression Inventory (BDI-II) score was 30.2±8.5 at baseline and 8.5±7.8 at 16weeks. Over 50% of the participants were in remission (HAM-D-17 score ≤7) at the end of treatment. Of the hypothesized predictors, severe depression at baseline (p=0.02), stressful life events during the first (p=0.03) and last (p<0.0001) 8weeks of treatment, and the completion of CBT homework assignments (p=0.001) predicted depression outcomes. History of prior episodes, anxiety symptoms, antidepressant therapy at study enrollment, and medical hospitalizations or emergency department visits during treatment did not predict treatment outcome.

CONCLUSIONS

Patients who are under considerable stress do not respond as well to evidence-based treatments for depression as do patients with less stress. If future studies support these findings, more work will be needed to better address stressful life events in patients who may otherwise remain at high risk for mortality and medical morbidity following depression treatment.

Mood disturbance and depression in Arab women following hospitalisation from acute cardiac conditions: a cross-sectional study from Qatar

OBJECTIVES

Depression is associated with increased morbidity and mortality rates among cardiovascular patients. Depressed patients have three times higher risk of death than those who are not. We sought to determine the presence of depressive symptoms, and whether gender and age are associated with depression among Arab patients hospitalised with cardiac conditions in a Middle Eastern country.

SETTING

Using a non-probability convenient sampling technique, a cross-sectional survey was conducted with 1000 Arab patients ≥20 years who were admitted to cardiology units between 2013 and 2014 at the Heart Hospital in Qatar. Patients were interviewed 3 days after admission following the cardiac event. Surveys included demographic and clinical characteristics, and the Arabic version of the Beck Depression Inventory Second Edition (BDI-II). Depression was assessed by BDI-II clinical classification scale.

RESULTS

15% of the patients had mild mood disturbance and 5% had symptoms of clinical depression. Twice as many females than males suffered from mild mood disturbance and clinical depression symptoms, the majority of females were in the age group 50 years and above, whereas males were in the age group 40-49 years. χ(2) Tests and multivariate logistic regression analyses indicated that gender and age were statistically significantly related to depression (p<0.001 for all).

CONCLUSIONS

Older Arab women are more likely to develop mood disturbance and depression after being hospitalised with acute cardiac condition. Gender and age differences approach, and routine screening for depression should be conducted with all cardiovascular patients, especially for females in the older age groups. Mental health counselling should be available for all cardiovascular patients who exhibit depressive symptoms.

Cardiac rehabilitation after spontaneous coronary artery dissection

PURPOSE

Although cardiac rehabilitation (CR) improves outcomes in patients after atherosclerotic myocardial infarctions, little is known of the CR benefit among patients with spontaneous coronary artery dissection (SCAD), who are primarily young, otherwise healthy women. The purpose of this study was to describe SCAD patient outcomes in phase 2 outpatient CR.

METHODS

Patients with SCAD who enrolled in CR were retrospectively identified. Patients participated in standard CR, which included supervised and independent flexibility, stretching, aerobic, and strength training exercises. Patients received counseling regarding nutrition, weight and stress management. Assessments at baseline and program completion included cardiopulmonary exercise testing or 6-Minute Walk Test, body composition using plethysmography, depression (Patient Health Questionnaire-9), and stress (a scale of 1-10) scores.

RESULTS

Nine patients, all women, enrolled in CR an average of 12.3 days (range, 7-21 days) after their SCAD event, with one enrolling again after a recurrence. Cardiac rehabilitation was well received, with participants completing an average of 28 CR sessions (range, 5-39 sessions). Patients did not report cardiac symptoms and there were no adverse events during exercise testing or training. Peak oxygen uptake increased by an average of 18% (n = 4) and 6-minute walk distance increased 22% (n = 4). Average body mass decreased 1.1 kg, fat mass decreased 1.6 kg, and lean mass increased 0.4 kg. Depression and stress scores improved by an average of 2.3 and 1.3 points, respectively.

CONCLUSIONS

Standard CR beginning 1 to 2 weeks after SCAD seems to be feasible and safe and results in improved aerobic capacity, body composition, and measures of depression and stress. Because of these benefits, we recommend that patients with SCAD participate in CR.

Enhancing Cardiac Rehabilitation With Stress Management Training: A Randomized, Clinical Efficacy Trial

BACKGROUND

Cardiac rehabilitation (CR) is the standard of care for patients with coronary heart disease. Despite considerable epidemiological evidence that high stress is associated with worse health outcomes, stress management training (SMT) is not included routinely as a component of CR.

METHODS AND RESULTS

One hundred fifty-one outpatients with coronary heart disease who were 36 to 84 years of age were randomized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT), with assessments of stress and coronary heart disease biomarkers obtained before and after treatment. A matched sample of CR-eligible patients who did not receive CR made up the no-CR comparison group. All participants were followed up for up to 5.3 years (median, 3.2 years) for clinical events. Patients randomized to CR+SMT exhibited greater reductions in composite stress levels compared with those randomized to CR alone (P=0.022), an effect that was driven primarily by improvements in anxiety, distress, and perceived stress. Both CR groups achieved significant, and comparable, improvements in coronary heart disease biomarkers. Participants in the CR+SMT group exhibited lower rates of clinical events compared with those in the CR-alone group (18% versus 33%; hazard ratio=0.49; 95% confidence interval, 0.25-0.95; P=0.035), and both CR groups had lower event rates compared with the no-CR group (47%; hazard ratio=0.44; 95% confidence interval, 0.27-0.71; P<0.001).

CONCLUSIONS

CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with standard CR. Our findings indicate that SMT may provide incremental benefit when combined with comprehensive CR and suggest that SMT should be incorporated routinely into CR.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00981253.

Reporting of Posttraumatic Stress Disorder and Cardiac Misconceptions Following Cardiac Rehabilitation

PURPOSE

Approximately 15% of cardiac patients experience posttraumatic stress disorder (PTSD), double the incidence seen in the general community. Posttraumatic stress disorder can seriously affect psychological and physical recovery. This study assessed how many patients reported symptoms of PTSD following a cardiac event and examined whether there was any change after completing a cardiac rehabilitation (CR) program. Associations between PTSD and anxiety, depression, and cardiac misconceptions were also explored.

METHODS

This was a prospective cohort study using repeated measures. All patients eligible for the hospital CR program were invited to complete questionnaires assessing psychological distress and beliefs about heart disease before (T1) and after (T2) completing the CR program.

RESULTS

Questionnaires at T1 were returned by 105 patients. Of these, 24% reported symptoms of PTSD, 18% high anxiety, and 9% high levels of depression. At T2, 67 patients returned questionnaires, showing that 9% of patients continued to experience PTSD. These patients experienced significantly higher levels of anxiety (t = -4.77; P < .001) and depression (t = -3.64; P < .001). Intrusive thoughts and hyperarousal were significantly lower at T2 (t = 2.32; P = .02 and t = 3.01; P = .01, respectively). More misconceptions were associated with higher levels of anxiety and depression; however, the number of cardiac misconceptions remained similar throughout. Caucasians reported significantly fewer misconceptions than non-Caucasian patients, except for beliefs about myocardial infarction. Patients had fewer misconceptions about their own specific condition.

CONCLUSIONS

These findings suggest that screening for symptoms of PTSD after completion of a CR program would be helpful in identifying patients who would benefit from specialist psychological support.

Sound mind vs sound heart

Depressive and anxiety disorders have both have been associated with an increased risk of cardiovascular disease. This article highlights the multifactorial and bidirectional interaction between cardiovascular diseases, depression and anxiety, and the need for early assessment, diagnosis and intervention.

Cardiac Risk Markers and Response to Depression Treatment in Patients With Coronary Heart Disease

BACKGROUND

Depression is associated with an increased risk of mortality in patients with coronary heart disease. There is evidence that this risk may be reduced in patients who respond to depression treatment. The purpose of this study was to determine whether cardiac risk markers predict poor response to depression treatment and, second, whether they improve with successful treatment.

METHODS

One hundred fifty-seven patients with stable coronary heart disease who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for a moderate to severe major depressive episode were treated with cognitive behavior therapy, either alone or combined with an antidepressant, for up to 16 weeks. Depression, physical activity, sleep quality, thyroid hormones (total thyroxine [T4] and free T4), and inflammatory blood markers (C-reactive protein, interleukin-6, tumor necrosis factor) were assessed at baseline and after 16 weeks of treatment.

RESULTS

The mean (SD) Beck Depression Inventory scores were 30.2 (8.5) at baseline and 8.5 (7.8) at 16 weeks. More than 50% of the participants met the criteria for depression remission (17-item Hamilton Rating Scale for Depression ≤ 7) at 16 weeks. Only free T4 thyroid hormone at baseline predicted poor response to depression treatment after adjustment for potential confounders (p = .004). Improvement in sleep quality (p = .012) and physical activity level (p = .041) correlated with improvement in depression. None of the inflammatory markers predicted posttreatment depression or changed with depression.

CONCLUSIONS

Thyroid hormone (T4) level predicted depression treatment outcome, and improvement in depression correlated with improvement in sleep and physical activity. More detailed studies of thyroid function and objective assessments of sleep and physical activity in relation to depression improvement and cardiac outcomes are needed.

Protective Effect of Regular Physical Activity on Depression After Myocardial Infarction: The HUNT Study

PURPOSE

To study if physical activity within the recommended level over time was associated with risk of developing depression after the first myocardial infarction in older adults.

METHODS

Men (n = 143) and women (n = 46) who had reached the age of 60 years in 2006-2008 who participated in the Nord-Trøndelag Health Study (HUNT1, 1984-1986; HUNT2, 1995-1997; HUNT3, 2006-2008) without any mental illness or cardiovascular disease at baseline in HUNT2 and who experienced their first myocardial infarction before HUNT3 were included. Based on the patterns of physical activity from HUNT1 to HUNT2, the sample was divided into 4 groups: persistently inactive, from active to inactive, from inactive to active, and persistently active. The primary outcome, post-myocardial infarction depression symptoms, was measured with the Hospital, Anxiety and Depression Scale in HUNT3.

RESULTS

In HUNT3, 11% of participants had depression. After multivariable adjustment, those who were persistently active had significantly lower odds of being depressed (odds ratio 0.28; 95% confidence interval, 0.08-0.98) compared with those who were persistently inactive. Additionally, a significant test for trend (P = .033) of lowering odds of depression was observed across all 4 categories of physical activity patterns at baseline.

CONCLUSIONS

In this small sample of initially healthy adults, we observed a long-term protective effect of regular physical activity on the development of depression following myocardial infarction.

Which Factors Unexpectedly Increase Depressive Symptom Severity in Patients at the End of a Cardiac Rehabilitation Program?

OBJECTIVE

To investigate predictors of depressive symptom aggravation at the end of a cardiac rehabilitation (CR) program.

METHODS

The design of the study was retrospective. The administrative data were obtained from the database of the CR department of a heart hospital in Iran. The demographic and clinical information of 615 CR patients between January 2000 and January 2010 was analyzed using binary logistic regression analysis.

RESULTS

The results showed that 10.7% of the patients completed the CR program with aggravated depressive symptoms. After adjustment for gender, age, and pre-intervention depression score, lower education level (p<0.05) and smoking (p<0.01) were significant predictors of increased depressive symptoms at the end of the program. Our model variables could explain 6% to 13% of the dependent variable variance.

CONCLUSION

The results suggest that targeting patients who are less literate or who smoke could allow for taking the required measures to prevent or control depression at the end of a CR program. It is suggested that future studies consider other variables.

The association between cardiac rehabilitation and mortality risk for myocardial infarction patients with and without depressive symptoms

BACKGROUND

Post-myocardial infarction (MI) depression is associated with reduced adherence to cardiac rehabilitation (CR) and increased mortality risk. The present study investigated whether all-cause mortality reduction associated with CR is different for MI-patients with and without depressive symptoms.

METHODS

Data of 2198 post-MI patients from the Depression after Myocardial Infarction (DepreMI) study and Myocardial Infarction and Depression Intervention Trial (MIND-IT) was used. Depression was assessed at hospitalization, defined as a score≥10 on the Beck Depression Inventory (BDI). Participation in CR was assessed with a self-report questionnaire, 12 months post-MI. Cox regression was used to estimate hazard ratios (HR) for all-cause mortality, up till 10 years post-MI. Missing data was imputed, using multiple imputation.

RESULTS

878 (52%) Patients attended CR, 517 (26%) patients had a BDI score ≥10, and 379 (18%) patients died during the follow-up period. Overall, CR was not associated with a lower mortality risk (HR: 0.83; 0.54-1.30; p=0.41), adjusted for age, sex, left ventricle ejection fraction, previous MI, and past or current heart failure. However, there was a significant interaction between depression and CR on mortality (HR: 0.49; 0.27-0.90; p=0.02). CR was significantly associated with reduced mortality in depressed patients (HR: 0.48; 0.28-0.84; p=0.01), but not in non-depressed patients (HR: 1.09; 0.63-1.89; p=0.74).

LIMITATIONS

Patients were not randomized to CR. We had no information about the specific reasons of clinicians to offer CR and about the patients' motives to participate.

CONCLUSIONS

CR was associated with reduced mortality risk only for MI-patients with depression. Clinicians should therefore particularly encourage MI-patients with depression to participate in CR.

Clinical and Prognostic Value of Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Eisenmenger Syndrome

OBJECTIVES

Eisenmenger syndrome (ES) is commonly associated with depressive symptoms and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP). We investigated the predictive value of depressive symptoms and NTproBNP levels for long-term outcomes in patients with ES.

METHODS

Blood was drawn to measure NT-proBNP, and depressive symptoms were measured using the Korean version of the Beck Depression Inventory (BDI) in an outpatient clinic sample of 64 patients with ES (67% female; median age = 41.5 years [range, 21.0-74.8 years]). Cardiac events (hospitalization, emergency department visits, and cardiac death) were monitored during 3 years of follow-up.

RESULTS

During the follow-up period, 15 (23.4%) patients experienced a cardiac event. The combination of depressive symptoms and NT-proBNP levels better predicted future cardiac events than either variable alone. Patients with NT-proBNP > 510 pg/ml and a total BDI score > 10 had a 9.6 times higher risk for cardiac events than did patients with NT-proBNP ≤ 510 pg/ml or total BDI score ≤ 10 (p < .001).

CONCLUSIONS

Depressive symptoms and NT-proBNP levels are both associated with adverse clinical outcomes in ES.

Exercise and the cardiovascular system: clinical science and cardiovascular outcomes

Substantial evidence has established the value of high levels of physical activity, exercise training (ET), and overall cardiorespiratory fitness in the prevention and treatment of cardiovascular diseases. This article reviews some basics of exercise physiology and the acute and chronic responses of ET, as well as the effect of physical activity and cardiorespiratory fitness on cardiovascular diseases. This review also surveys data from epidemiological and ET studies in the primary and secondary prevention of cardiovascular diseases, particularly coronary heart disease and heart failure. These data strongly support the routine prescription of ET to all patients and referrals for patients with cardiovascular diseases, especially coronary heart disease and heart failure, to specific cardiac rehabilitation and ET programs.

Treatment of affective disorders in cardiac disease

Patients with cardiovascular disease (CVD) commonly have syndromal major depression, and depression has been associated with an increased risk of morbidity and mortality. Prevalence of depression is between 17% and 47% in CVD patients. Pharmacologic and psychotherapeutic interventions have long been studied, and in general are safe and somewhat efficacious in decreasing depressive symptoms in patients with CVD. The impact on cardiac outcomes remains unclear. The evidence from randomized controlled clinical trials indicates that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe, and likely to be effective in the treatment of depression in patients with CVD. This review describes the prevalence of depression in patients with CVD, the physiological links between depression and CVD, the treatment options for affective disorders, and the clinical trials that demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population. Great progress has been made in understanding potential mediators between major depressive disorder and CVD—both health behaviors and shared biological risks such as inflammation.

Depressive symptoms at discharge from rehabilitation predict future cardiovascular-related hospitalizations

OBJECTIVES

Depression is associated with poor prognosis in patients with cardiovascular disease (CVD). We hypothesized that depressive symptoms at discharge from a cardiac rehabilitation program are associated with an increased risk of future CVD-related hospitalizations.

METHODS

We examined 486 CVD patients (mean age=59.8±11.2) who enrolled in a comprehensive 3-month rehabilitation program and completed the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). At follow-up we evaluated the predictive value of depressive symptoms for CVD-related hospitalizations, controlling for sociodemographic factors, cardiovascular risk factors, and disease severity.

RESULTS

During a mean follow-up of 41.5±15.6 months, 63 patients experienced a CVD-related hospitalization. The percentage of depressive patients (HADS-D≥8) decreased from 16.9% at rehabilitation entry to 10.7% at discharge. Depressive symptoms at discharge from rehabilitation were a significant predictor of outcome (HR 1.32, 95% CI 1.09-1.60; p=0.004). Patients with clinically relevant depressive symptoms at discharge had a 2.5-fold increased relative risk of poor cardiac prognosis compared to patients without clinically relevant depressive symptoms independently of other prognostic variables.

CONCLUSION

In patients with CVD, depressive symptoms at discharge from rehabilitation indicated a poor cardiac prognosis.

Health care 2020: reengineering health care delivery to combat chronic disease

Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic.

Associations between television watching and car riding behaviors and development of depressive symptoms: a prospective study

OBJECTIVE

To examine the longitudinal association between sedentary behaviors and risk of development of depressive symptoms.

PATIENTS AND METHODS

The study population consisted of 4802 participants in the Aerobics Center Longitudinal Study (1012 women and 3790 men) aged 18 to 80 years who did not report depressive moods when they completed a health survey during 1982 in which they reported their time spent watching television (TV) and riding in a car each week. All participants completed a follow-up health survey when they responded to the 10-item Center for Epidemiologic Studies Depression Scale. Those who scored 8 or more on the Center for Epidemiologic Studies Depression Scale were considered to have depressive symptoms.

RESULTS

Among the 4802 participants, 568 reported depressive symptoms during a mean follow-up of 9.3 years. After multivariate adjustment including moderate- and vigorous-intensity physical activity, time riding in a car, time watching TV, and combined time spent in the 2 sedentary behaviors were positively associated with depressive symptoms (each P<.05 for trend). Individuals who reported 9 h/wk or more riding in a car, more than 10 h/wk watching TV, or 19 h/wk or more of combined sedentary behavior had 28%, 52%, and 74% greater risk of development of depressive symptoms than those who reported less than 5 h/wk, less than 5 h/wk, or less than 12 h/wk, respectively, after adjusting for baseline covariates and moderate- and vigorous-intensity physical activity. The positive association between time riding in a car or time watching TV and depressive symptoms was only observed among individuals who did not meet the current physical activity guidelines.

CONCLUSION

More time reported in these 2 sedentary behaviors was positively associated with depressive symptoms. However, the direct associations between time spent in car riding and TV viewing and depressive symptoms were only significant among those who did not meet the current physical activity recommendations.

Depression, coronary artery disease, and physical activity: how much exercise is enough?

PURPOSE

The mechanisms by which depressive symptoms negatively affect clinical outcomes in patients with coronary artery disease (CAD) remain poorly understood. Previous interventions that have attempted to treat depressive symptoms in patients with CAD to improve their clinical outcomes have been disappointing. Our objectives were, among a cohort of CAD patients, to evaluate the impact of depressive symptoms over time, controlling for comorbidity, in determining both successful long-term lifestyle change (ie, increased physical activity), and cardiovascular morbidity and mortality outcomes. In addition, we examined the impact of physical activity changes over time on 2 known mediators of cardiovascular morbidity: parasympathetic tone and inflammation.

METHODS

Clinical data were previously collected (2004-2006) from 242 elective/urgent coronary angioplasty patients who participated in a prospective randomized controlled trial evaluating the efficacy of a behavioral intervention versus an educational control to motivate physical activity over 12 months. Exclusion criteria included: (1) inability to walk; (2) enrollment in other risk-reduction trials; (3) non-English speaking; and (4) lack of cardiologist's permission to increase physical activity. Participants were assessed every 2 months for interval clinical events and physical activity. In addition, biomarkers were collected at baseline and at 12 months in a subset of 54 participants; these biomarkers included low-frequency heart rate variability (lfHRV), high-frequency heart rate variability (hfHRV), serum C-reactive protein, interleukin-6, and salivary cortisol.

FINDINGS

The mean age of participants was 63 years and 30% were female. Overall, 37% had high depressive symptoms at baseline. Patients with high depressive symptoms who achieved an increase in physical activity of ≥336 kilocalories(kcal)/week by 12 months had significantly lower rates of cardiovascular morbidity/mortality (5.1% vs. 21.3%; odds ratio [OR], 0.20, [95% CI, 0.04-0.98]; P = 0.03). In a multivariate model examining cardiovascular morbidity/mortality in patients with high depressive symptoms, an increase in physical activity of ≥336 kcal/week reduced the risk of new cardiovascular morbidity/mortality (OR, 0.11 [95% CI, 0.02-0.81]; P < 0.03), and comorbidity increased the risk (OR, 1.58 [95% CI, 1.18-2.13]; P = 0.002). In a generalized structural equation model, increasing physical activity by ≥336 kcal/week decreased the risk of complications, and comorbidity increased the risk. Furthermore, increasing physical activity (≥336 kcal/week) predicted an increase in hfHRV, a marker of parasympathetic tone, and the increase in hfHRV predicted a reduction in the proinflammatory mediators interleukin-6 and C-reactive protein.

IMPLICATIONS

This study found a threshold in physical activity in CAD patients with depressive symptoms that is associated with a decrease in cardiovascular morbidity and mortality. Exercise maintenance at this level may improve clinical outcomes via enhanced parasympathetic tone and decreased inflammation. ClinicalTrials.gov identifier: NCT00248846.

Randomised controlled trial of a 12 week yoga intervention on negative affective states, cardiovascular and cognitive function in post-cardiac rehabilitation patients

BACKGROUND

Negative affective states such as anxiety, depression and stress are significant risk factors for cardiovascular disease, particularly in cardiac and post-cardiac rehabilitation populations.Yoga is a balanced practice of physical exercise, breathing control and meditation that can reduce psychosocial symptoms as well as improve cardiovascular and cognitive function. It has the potential to positively affect multiple disease pathways and may prove to be a practical adjunct to cardiac rehabilitation in further reducing cardiac risk factors as well as improving self-efficacy and post-cardiac rehabilitation adherence to healthy lifestyle behaviours.

METHOD AND DESIGN

This is a parallel arm, multi-centre, randomised controlled trial that will assess the outcomes of post- phase 2 cardiac rehabilitation patients assigned to a yoga intervention in comparison to a no-treatment wait-list control group. Participants randomised to the yoga group will engage in a 12 week yoga program comprising of two group based sessions and one self-administered home session each week. Group based sessions will be led by an experienced yoga instructor. This will involve teaching beginner students a hatha yoga sequence that incorporates asana (poses and postures), pranayama (breathing control) and meditation. The primary outcomes of this study are negative affective states of anxiety, depression and stress assessed using the Depression Anxiety Stress Scale. Secondary outcomes include measures of quality of life, and cardiovascular and cognitive function. The cardiovascular outcomes will include blood pressure, heart rate, heart rate variability, pulse wave velocity, carotid intima media thickness measurements, lipid/glucose profiles and C-reactive protein assays. Assessments will be conducted prior to (week 0), mid-way through (week 6) and following the intervention period (week 12) as well as at a four week follow-up (week 16).

DISCUSSION

This study will determine the effect of yoga practice on negative affective states, cardiovascular and cognitive function in post-phase 2 cardiac rehabilitation patients. The findings may provide evidence to incorporate yoga into standardised cardiac rehabilitation programs as a practical adjunct to improve the management of psychosocial symptoms associated with cardiovascular events in addition to improving patients' cognitive and cardiovascular functions.

TRIAL REGISTRATION

ACTRN12612000358842.

Gender, race and cardiac rehabilitation in the United States: is there a difference in care?

Coronary heart disease is the leading cause of death within the United States, involving both genders and among all races and ethnic populations. Cardiac rehabilitation (CR) has been shown to significantly improve morbidity and mortality, and these benefits extend to individuals of both genders and all ages with coronary heart disease. Despite this, referral and participation rates remain surprisingly low. Furthermore, women and minorities have even lower referral rates than do their male and white counterparts. Over the course of this article, we will review CR referral and participation among women, as well as racial and ethnic minorities in the United States. We will also examine barriers to CR participation among these subgroups.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

The relationship between heart and 'inner self' from Aristotle to current clinical practice

Modern songs, films, novels and daily speech often use heart imagery to illustrate 'inner self' experiences, such as deeply felt emotions. Where do these ideas come from and what relevance (if any) do they have for medicine today? This article explores some of the key origins and periods of development of heart/'inner self' ideas before considering the significance of heart/'inner self' interactions in modern clinical practice: from Aristotelian anatomy and the translated Hebrew Scriptures; through Shakespeare, William Harvey and the Protestant Reformation; to theories of emotion and modern-day cardiology. I conclude that heart/'inner self' interactions exist in clinically significant ways, but are poorly understood and under-recognised in healthcare settings. Greater integration of cardiovascular and psychosocial medicine would improve patient care.

[Depression in Acute Coronary Syndromes: Application of the Beck Depression Inventory]

BACKGROUND

Depression has been related to the occurrence of cardiovascular diseases, and also appears to increase the risk of death from coronary artery disease. The presence of depression after the occurrence of an acute coronary syndrome (ACS) and its relationship with socioeconomic factors has not been studied in Colombia.

OBJECTIVE

To describe the frequency of depression and associated factors in patients hospitalized with an ACS.

METHODS

A cross-sectional study was carried out between April and May 2008 in three coronary care units in Santa Marta, Colombia. The presence of depression was evaluated with the Beck Depression Inventory (BDI). Depression was considered to be present if BDI was equal or greater than 10. The relationship between the presence of depression and demographic, clinic and laboratory characteristics was analyzed.

RESULTS

A BDI score ≥10 (any degree of depression) was seen in 21 (63.64%) of the patients. In 9 out of 10 (91.66%) patients without stable income had depression in contrast to 12 out of 23 (57.14%) with stable income (P=.037). Depression was found in in 8 of the 8 (100%) patients with electrocardiographic pathological T wave inversion, in contrast to 13 out of the 25 (52%) without changes in T wave (P=.014). Depression was detected in 17 of 22 (77.27%) patients who smoked cigarettes versus 4 of 11 (36.36%) of patients who have never smoked (P=.021).

CONCLUSIONS

Depressive symptoms are significantly present in patients suffering an acute coronary syndrome. Unemployment, pathological T wave inversion, and smoking seem to be associated with the presence of depressive symptoms after an acute coronary event.

Assessing depression in cardiac patients: what measures should be considered?

It is highly recommended to promptly assess depression in heart disease patients as it represents a crucial risk factor which may result in premature deaths following acute cardiac events and a more severe psychopathology, even in cases of subsequent nonfatal cardiac events. Patients and professionals often underestimate or misjudge depressive symptomatology as cardiac symptoms; hence, quick, reliable, and early mood changes assessments are warranted. Failing to detect depressive signals may have detrimental effects on these patients' wellbeing and full recovery. Choosing gold-standard depression investigations in cardiac patients that fit a hospitalised cardiac setting well is fundamental. This paper will examine eight well established tools following Italian and international guidelines on mood disorders diagnosis in cardiac patients: the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI). Though their strengths and weaknesses may appear to be homogeneous, the BDI-II and the PHQ are more efficient towards an early depression assessment within cardiac hospitalised patients.

Effects of cardiac rehabilitation in diabetic patients: both cardiac and noncardiac factors determine improvement in exercise capacity

BACKGROUND

Diabetic patients have a worse prognosis than nondiabetic patients after myocardial infarction. Although exercise improves risk factors, exercise capacity, and mortality, it is still unclear if these benefits are the same as in nondiabetics. Furthermore, although exercise tolerance is predicted by systolic and diastolic dysfunction in nondiabetics, its role as a predictor of exercise capacity in diabetics remains unclear.

HYPOTHESIS

Diabetics and nondiabetics see a similar improvement in their cardiac risk factors and exercise parameters from exercise-based cardiac rehabilitation (CR).

METHODS

A series of 370 diabetics and 942 nondiabetics entered a 36-session outpatient CR program after interventions for coronary heart disease or after bypass or cardiac valve surgery. The program consisted of physical exercise, lifestyle modification, and pharmacotherapy.

RESULTS

Quality of life, weight, blood pressure, and lipid profiles improved significantly in both groups during the 12-week program. Baseline metabolic equivalents (METs) were lower in diabetics vs nondiabetics at the start of CR (2.4 vs 2.7, P < 0.001). Although both groups increased their exercise capacity, diabetics had less improvement (change in METs 1.7 vs 2.6, P < 0.001). Significant predictors for improvement after CR included age, sex, and weight, as well as both systolic and diastolic function. After adjustment for these, diabetes remained a significant predictor of reduced improvement in exercise capacity.

CONCLUSIONS

Diabetics saw a significant benefit in quality of life, weight, exercise tolerance, and cardiac risk factors, but to a lesser extent when compared with nondiabetics. The mechanisms for poorer improvement in diabetics following CR also include noncardiac factors and require further study.

Cardiac rehabilitation past, present and future: an overview

Cardiac Rehabilitation has evolved over the past decades from a simple monitoring for the safe return to physical activities to a multidisciplinary approach that focuses on patient education, individually tailored exercise training, modification of the risk factors and the overall well-being of the cardiac patients. It has been proven to be an effective tool for the care of the patients with heart disease. Recent research in cardiac rehabilitation has demonstrated that tremendous benefits can be derived from the optimal use of cardiac rehabilitation in patients with various cardiac pathologies including ischemic heart disease, heart failure and post heart surgery. The benefits of cardiac rehabilitation include mortality reduction, symptom relief, reduction in smoking and improved exercise tolerance, risk factors modification and the overall psychosocial wellbeing. Unfortunately, cardiac rehabilitation remains considerably underutilized mainly because of referral problems and poor enrollment. The development of alternate approaches and the use of transtelephonic and other means of monitoring and surveillance will help expand the utilization of cardiac rehabilitation.

Tai chi chuan exercise for patients with cardiovascular disease

Exercise training is the cornerstone of rehabilitation for patients with cardiovascular disease (CVD). Although high-intensity exercise has significant cardiovascular benefits, light-to-moderate intensity aerobic exercise also offers health benefits. With lower-intensity workouts, patients may be able to exercise for longer periods of time and increase the acceptance of exercise, particularly in unfit and elderly patients. Tai Chi Chuan (Tai Chi) is a traditional Chinese mind-body exercise. The exercise intensity of Tai Chi is light to moderate, depending on its training style, posture, and duration. Previous research has shown that Tai Chi enhances aerobic capacity, muscular strength, balance, and psychological well-being. Additionally, Tai Chi training has significant benefits for common cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, poor exercise capacity, endothelial dysfunction, and depression. Tai Chi is safe and effective in patients with acute myocardial infarction (AMI), coronary artery bypass grafting (CABG) surgery, congestive heart failure (HF), and stroke. In conclusion, Tai Chi has significant benefits to patients with cardiovascular disease, and it may be prescribed as an alternative exercise program for selected patients with CVD.

Exercise for depression

BACKGROUND

Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychological therapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. This is an update of an earlier review first published in 2009.

OBJECTIVES

To determine the effectiveness of exercise in the treatment of depression in adults compared with no treatment or a comparator intervention.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Controlled Trials Register (CCDANCTR) to 13 July 2012. This register includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years); MEDLINE (1950 to date); EMBASE (1974 to date) and PsycINFO (1967 to date). We also searched www.controlled-trials.com, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No date or language restrictions were applied to the search.We conducted an additional search of the CCDANCTR up to 1st March 2013 and any potentially eligible trials not already included are listed as 'awaiting classification.'

SELECTION CRITERIA

Randomised controlled trials in which exercise (defined according to American College of Sports Medicine criteria) was compared to standard treatment, no treatment or a placebo treatment, pharmacological treatment, psychological treatment or other active treatment in adults (aged 18 and over) with depression, as defined by trial authors. We included cluster trials and those that randomised individuals. We excluded trials of postnatal depression.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data on primary and secondary outcomes at the end of the trial and end of follow-up (if available). We calculated effect sizes for each trial using Hedges' g method and a standardised mean difference (SMD) for the overall pooled effect, using a random-effects model risk ratio for dichotomous data. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis. Where trials provided several 'doses' of exercise, we used data from the biggest 'dose' of exercise, and performed sensitivity analyses using the lower 'dose'. We performed subgroup analyses to explore the influence of method of diagnosis of depression (diagnostic interview or cut-off point on scale), intensity of exercise and the number of sessions of exercise on effect sizes. Two authors performed the 'Risk of bias' assessments. Our sensitivity analyses explored the influence of study quality on outcome.

MAIN RESULTS

Thirty-nine trials (2326 participants) fulfilled our inclusion criteria, of which 37 provided data for meta-analyses. There were multiple sources of bias in many of the trials; randomisation was adequately concealed in 14 studies, 15 used intention-to-treat analyses and 12 used blinded outcome assessors.For the 35 trials (1356 participants) comparing exercise with no treatment or a control intervention, the pooled SMD for the primary outcome of depression at the end of treatment was -0.62 (95% confidence interval (CI) -0.81 to -0.42), indicating a moderate clinical effect. There was moderate heterogeneity (I² = 63%).When we included only the six trials (464 participants) with adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment, the pooled SMD for this outcome was not statistically significant (-0.18, 95% CI -0.47 to 0.11). Pooled data from the eight trials (377 participants) providing long-term follow-up data on mood found a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03).Twenty-nine trials reported acceptability of treatment, three trials reported quality of life, none reported cost, and six reported adverse events.For acceptability of treatment (assessed by number of drop-outs during the intervention), the risk ratio was 1.00 (95% CI 0.97 to 1.04).Seven trials compared exercise with psychological therapy (189 participants), and found no significant difference (SMD -0.03, 95% CI -0.32 to 0.26). Four trials (n = 300) compared exercise with pharmacological treatment and found no significant difference (SMD -0.11, -0.34, 0.12). One trial (n = 18) reported that exercise was more effective than bright light therapy (MD -6.40, 95% CI -10.20 to -2.60).For each trial that was included, two authors independently assessed for sources of bias in accordance with the Cochrane Collaboration 'Risk of bias' tool. In exercise trials, there are inherent difficulties in blinding both those receiving the intervention and those delivering the intervention. Many trials used participant self-report rating scales as a method for post-intervention analysis, which also has the potential to bias findings.

AUTHORS' CONCLUSIONS

Exercise is moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller effect in favour of exercise. When compared to psychological or pharmacological therapies, exercise appears to be no more effective, though this conclusion is based on a few small trials.

Emotional distress, alexithymia, and coping as predictors of cardiac rehabilitation outcomes and attendance

PURPOSE

The purpose of this study was to examine emotional distress, alexithymia, and coping styles as predictors of cardiac rehabilitation (CR) outcomes and attendance.

METHODS

Participants included 56 patients in an outpatient CR program (65% male, 59% white, M = 61.1 years) who completed self-report measures of emotional distress (ie, depressive and anxiety symptoms), alexithymia, and coping styles (ie, approach and avoidance coping). CR outcomes recorded at entry and completion of the program included blood cholesterol, oxygen uptake ((Equation is included in full-text article.)VO(2max)), knowledge about cardiac disease, and self-reported lipid consumption. Attendance was also recorded as a measure of adherence.

RESULTS

Significant improvements were observed in oxygen uptake, high-density lipoprotein levels, disease knowledge, and self-reported lipid consumption. Older age was associated with less distress, and anxiety and higher education were associated with better attendance. Higher alexithymia (ie, greater difficulty processing emotion) was associated with increased low-density lipoprotein cholesterol, and alexithymia predicted increased self-reported lipid consumption in the context of higher approach coping.

CONCLUSIONS

CR is associated with physical and quality-of-life benefits, as well as increased knowledge about cardiac disease management. However, coping strategies that are generally beneficial (approach coping) may be associated with negative health behavior among individuals who have difficulty processing emotion. Anxiety and lower education were associated with poorer attendance, perhaps indicating the need for intervention to prevent dropout.

Factors that influence obesity, functional capacity, anxiety and depression outcomes following a Phase III cardiac rehabilitation programme

AIMS AND OBJECTIVES

To examine changes in functional capacity, anxiety, depression and BMI in patients who completed a cardiac rehabilitation programme and to determine the influencing factors.

BACKGROUND

While the effectiveness of cardiac rehabilitation is long established, more studies are needed to examine the combined effectiveness of this multicomponent intervention and the factors that influence this in the changed profile of patients currently attending cardiac rehabilitation.

DESIGN

The study was a longitudinal retrospective study of patients following a six- or eight-week Phase III cardiac rehabilitation programme.

METHODS

The study recruited 154 patients. Functional capacity, anxiety, depression, weight, waist circumference and BMI were assessed at the beginning and end of cardiac rehabilitation. t-tests were used to assess changes over time, and multivariate regression analysis was used to determine the influence of factors on these changes.

RESULTS

Significant improvements were seen in functional capacity, waist circumference, weight and BMI, but not in depression and anxiety. Multivariate analysis revealed that being younger and less fit was associated with greater improvements in functional capacity while reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Models testing the influence of the factors on BMI, anxiety and depression were not significant.

CONCLUSION

Cardiac rehabilitation is still an effective method to instigate changes in cardiac risk factors despite the changes in patients profile attending programmes.

RELEVANCE TO CLINICAL PRACTICE

Continued encouragement of the historically less typical patients to participate in cardiac rehabilitation is needed as reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Despite psychosocial components within the programme, no significant improvements were observed over cardiac rehabilitation in depression or anxiety. While effectiveness was observed, there is room for further optimisation of practice and research by employing and documenting clearly the use of behavioural techniques.

Depression as a non-causal variable risk marker in coronary heart disease

BACKGROUND

After decades of investigations, explanations for the prospective association between depression and coronary heart disease (CHD) are still incomplete.

DISCUSSION

Depression is often suggested to be causally related to CHD. Based on the available literature, we would rather argue that depression can best be regarded as a variable risk marker, that is, a variable that fluctuates together with mechanisms leading to poor cardiovascular fitness. Despite numerous efforts, no evidence is found that manipulation of depression alters cardiovascular outcomes--a key premise for determining causality. To explain the concept of a variable risk marker, we discuss several studies on the heterogeneity of depression suggesting that depression is particularly harmful for the course of cardiovascular disease when it appears to be a physiological consequence of the cardiovascular disease itself.

SUMMARY

We conclude that instead of depression being a causal risk factor for CHD, the association between depression and CHD is likely confounded, at least by the cardiac disease itself.

A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease

OBJECTIVE

To quantify the efficacy of mental health (antidepressants & psychotherapies) and cardiac rehabilitation treatments for improving secondary event risk and depression among patients with coronary heart disease (CHD).

METHODS

Using meta-analytic methods, we evaluated mental health and cardiac rehabilitation therapies for a) reducing secondary events and 2) improving depression severity in patients with CHD. Key word searches of PubMed and Psychlit databases and previous reviews identified relevant trials.

RESULTS

Eighteen mental health trials evaluated secondary events and 22 trials evaluated depression reduction. Cardiac rehabilitation trials for the same categories numbered 17 and 13, respectively. Mental health treatments did not reduce total mortality (absolute risk reduction [ARR] = -0.001, confidence interval [95% CI] = -0.016 to 0.015; number needed to treat [NNT] = ∞), showed moderate efficacy for reducing CHD events (ARR = 0.029, 95% CI = 0.007 to 0.051; NNT = 34), and a medium effect size for improving depression (Cohen d = 0.297). Cardiac rehabilitation showed similar efficacy for treating depression (d = 0.23) and reducing CHD events (ARR = 0.017, 95% CI = 0.007 to 0.026; NNT = 59) and reduced total mortality (ARR = 0.016, 95% CI = 0.005 to 0.027; NNT = 63).

CONCLUSIONS

Among patients with CHD, mental health treatments and cardiac rehabilitation may each reduce depression and CHD events, whereas cardiac rehabilitation is superior for reducing total mortality risk. The results support a continued role for mental health treatments and a larger role for mental health professionals in cardiac rehabilitation.